This course proposes an overview of current global health challenges drawing on the insights of several academic disciplines including medicine, public health, law, economics, social sciences and humanities. This interdisciplinary approach will guide the student into seven critical topics in global health.

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Foreign Policy, Trade and Health

Health policy has undergone profound changes during the last few decades. Although health has for a long time been an issue in international relations, it was for most of the 20th century perceived as a national and technical matter. This meant that solutions to health problems were seen to require primarily scientific and technological collaboration rather than political commitment. Along with the dramatic changes associated with globalisation, health is increasingly seen as a higher priority on international political agendas.
In Module 6, we discuss what triggered this political ‘revolution’ and its implications.

Conheça os instrutores

Rafael Ruiz De Castañeda

Institute of Global Health - Faculty of MedicineUniversity of Geneva

Antoine Flahault

Professor of Public Health and Director of the Institute of Global Health (Faculty of Medicine, University of Geneva) and co-Director of Centre Virchow-Villermé (Université Paris Descartes)University of Geneva and Université Paris Descartes – Sorbonne Paris Cité

[MUSIC]

I'm going to talk to you about medical humanitarian action and

what the ethical issues could be.

But before doing so, perhaps we have to think about what humanitarian medicine is.

It's a word which is widely used but often in very different ways.

Now, look at this list just for a minute and

tell me where you would put your mark, what do you think?

Now, one possible

definition of medical humanitarian action is the one which appears here.

And you see that certain words are very important.

It's medical but also public health practices.

It's selflessly delivered.

And there's a tension created between compelling health needs and

deprivation of resources.

So, you can already see that it's quite different from something when you're

a medical doctor in your own private practice or

when you work in a well resourced country as Switzerland, for example.

It can also not be defined only by specific medical practices or settings.

Often one thinks about refugees or natural disaster as where

medical humanitarian action takes place, that's correct.

But that is not what it is all about.

One thing which is very important that we're going to come back to later on

is that it implies fair choices and a collective responsibility.

Which again is quite different from individual medical action.

Let's now look at what makes humanitarian settings different from a normal medical

setting.

You have talked about global public health in the past weeks,

now we really come to a very particular situation

where the local health infrastructure may be completely destroyed or

seriously depleted and we need to act very quickly to save lives.

Then, of course resources are even much more constrained

than they would normally be.

What is also different is that you may not have any oversight mechanisms.

National government may not be functional anymore.

Local government may not be able to react, and

this also makes for impaired security, very often.

Which in a health situation particularly is also

important issue when it comes to patients, to health records for patients,

to confidentiality of health records, and so on.

Another major issue in humanitarian settings

is that qualified health personnel may no longer be available or

it may be difficult to get to the place where the disaster happened.

And thus it maybe be much more difficult than normally to

guarantee the quality of care.

Finally, another issue to consider is that communities and

people that have been affected by a crisis

are much more vulnerable even than under normal circumstances.

Keep this in mind when we talk later on about the ethical issues that appear

in humanitarian settings.

Before talking particularly about the ethical issues

in the humanitarian medical setting, let's just look at what means ethics.

Ethics are different from morals.

Ethics are more a reflection on morality and

on deciding in a given situation what could be good choices and wrong choices.

It gives us a better understanding of why we make these choices.

But in itself, it does not, making things good or bad, or black and white.

And you should not confuse it with religious beliefs or

with legal regulations or political opinions.

What is also very important to understand about ethics is that they don't provide

a single answer.

And particularly not when you look at a complex situation

as may be the case in medical humanitarian action.

Now, why have professionals worry about ethics?

If some of you who may be medical doctors,

you very well know that medical ethics should govern your medical practice.

Those of you who are involved in the field of public health

also know that there's something called public health ethics which govern how

you intervene in a population group.

When you look at medical actions in humanitarian settings,

you may also want to think about research ethics

as often research is very important in disaster situations.

But, more importantly so, you also will think about operational ethics,

which may be much less familiar to some of you.

Which means, how do you make operational choices in a certain situation,

given the fact that you can't do everything?

So, we'll come back to medical ethics, public health ethics, and

operational ethics In circumstances of humanitarian crises.

We're not going to look in this lecture at research ethics.

Medical ethics is a very, very old domain.

It started more than 2500 years ago when Hippocrates

said that a doctor should not harm his patients.

But then after 2nd World War another major addition

was made to medical ethics, which is beyond do no harm.

You should really respect the autonomy of your patients.

And this then comes to issues such as informed consent, and

informing the patient about what you are going to do.

Here, you have, I've mentioned, two of the most important codes which

is the medical code of the World Medical Association and the Declaration of Geneva.

Those are easily found on the Web.

Medical ethics, as you may know, has four basic principles.

Respect for autonomy, which relates to information and

understanding of the patient, consent, and also that you keep confidential and

private all matters you discuss with the patient.

Then of course, you should not harm a patient, but

your treatment should benefit him.

Although very often this is difficult because,

as we know, many treatments have secondary effects.

So, you have to weigh these two things.

And finally, fairness and equity becomes evermore important in a humanitarian

setting because how will you distribute benefits equitably

when a whole population is affected but the means are not there to help everybody.

Let me just come back to the issue of information understanding which is perhaps

at the center of medical ethics and particularly humanitarian situations.

There is always an imbalance in power between a doctor and his or her patient.

But this is even more so in a humanitarian situation where people are totally

destitute, totally dependent on the aid you are going to provide and

where you have much, more power because you have much more means.

You have the money and you are the only one who can help them.

They have no possibility to go elsewhere.

So there's an extra effort needed to ensure that people really understand

what you are going to provide to them and

they then can make a decision about what they want to do.

What is sufficient may also depend on the potential risk of a treatment.

For example, providing malaria treatment may have much less secondary effects

than providing a treatment for sleeping sickness, or providing a treatment for

long-term disease such as HIV and AIDS.

Doing an HIV test may have very bad repercussions for

a patient if found positive.

But doing a simple test for hypertension, may be much less severe.

So, how much you have to inform the patient and what the understanding of

the patient is, will depend on the type of treatment your provide.

However, this may be very difficult in situations where you work under great

stress, where there's very little time to provide this information but

you still have to keep these ethical standards in mind.

Confidentiality and privacy may be also very much compromised in settings where

a lot of patients are treated in a single room, where there is very little privacy.

Where also, it may be difficult to keep records safely because in the beginning

you don't have the right place to keep them safely.

So all these issues you should really think about and see how you can mitigate

them even in a difficult situation when you're working a crisis situation.

Now, let me move to harms and benefits.

Harms and benefits, you have a certain judgment on what harms and benefits for

a patient could be, but maybe the patient has a very different assessment of this.

For him, what you may perceive beneficial may not be perceived as such.

Let me go back to the example of an HIV test.

You give an HIV test.

The patient is found positive.

While you may think this is beneficial because now the patient can be put under

treatment before symptoms of AIDS appear, the patient may find this very,

very detrimental because he or she has to go back and inform the partner or

decide not to inform the partner because he fears discrimination or stigmatization.

So you always have to properly inform the patient before and

that the patient can decide what it means by harms and benefits.

On the other hand benefits will be rated to the type of care you can provide.

Now, the problem in many situations such as disasters,

conflict situations is that you have not all means available.

The better drugs you have, the better tests you have available,

the better competence the health professionals who work there have,

the better you will be able to provide quality care.

Finally, there may be certain risky situations which

relate to the law of a country or to habits, customs.

For example, female genital mutilation is very prevalent in certain countries.

And people working in humanitarian organizations have

been asked after delivery to close a vagina again.

Now, can a humanitarian organization do that?

Is that ethically sound?

Another issue is abortion.

In many countries, abortion is prohibited, however,

a woman being pregnant after being raped has the right to abortion.

Now, some humanitarian organizations provide abortion,

even if the law of the country prohibits it.

So these are situations where benefits and

harms have to be weighed also against the rules and laws of a country.

Finally, fairness and

equity, which is very important, because you decide what you provide to people.

It is not that the patients will have another choice of another provider.

So, if you decide to provide certain treatments, for

example for acute diseases like cholera or malaria, but you're not going to

provide treatment for chronic diseases such as diabetes or tuberculosis.

That is your decision.

Now, is this fair?

Is this equitable that one patient may get a treatment and another not?

You have at least to establish fair rules,

how people can access treatments that are not provided at your health facility and

how they can access them at other health facilities.

You also need to consider that sometimes the most vulnerable

may not come to your health facility.

So you have to look beyond the walls of the health facility to see who are those

in the community who fear perhaps coming for treatment because they are from

a stigmatized group or because they're not able to reach the facility or

because they fear their family or their community.

Or they lack of financial means.

You have to have all of these things in mind to be able to establish a system by

which even the most vulnerable will be able to reach the services you provide.

Now, let me move to public health ethics.

Public health ethics means that you don't any more to a single patient but

at the health of a whole population group.

So the collective interest now prevails over the individual interest.

And it is not longer the relationship between a care provider, as we

discussed previously, but between a whole population group and an organization.

Now, here we have a severe tension sometimes between medical ethics and

public health ethics.

First of all, all health interventions in humanitarian settings combine medical

with public health activities.

That is absolutely clear because vaccination, water and sanitation,

preventive measures such as education always are part of an health intervention.

Now, direct patient care and public health goals may sometimes clash.

It has happened, for example, that organizations have decided

not to provide tuberculosis treatment in a crisis situation.

Because they were not able to follow it through, so

the appearance of antibiotics resistance could be very high.

But at the same time,

people with tuberculosis would die because they were not getting treated.

That also happened, for example, in Haiti during the crisis,

that some organizations provided cholera care but would not or were not able to

carry out at the same time preventive activities in the population.

Now, this is nonsensical in some way because you treat the disease but

you don´t do anything for not having new cholera cases appear.

So these tensions have to be addressed and

this is also a question of where you put your resources first.

The issue is that often it is the doctor or the health care worker at the front who

is exposed to these tensions but doesn't have the power really

to make the decisions which are made at a higher level in the organization.

Let me now move to the operational ethics, which come from the medical and

the public health ethics, but even go to a higher level in the organization.

Because at some point it is decided what the organization is going to

provide in a certain situation and what not.

You may, for example, decide that you want to treat the most urgent

diseases first and leave others for later.

This is a photo taken during the exodus of the Hutus

after the genocide in Rwanda going into

the Democratic Republic of Congo arriving in Goma, a cholera epidemic broke out.

Of course, everybody was treating cholera patients, but

other diseases were not taken care of in the first weeks or the first days at least

of this, meaning that other people may have died from diseases such as malaria.

Another issue is limiting care.

Sometimes you decide there's a nutritional crisis and an organization may put up